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VBS 2017 Registration Form
(One Per Child)
Child's Name:
Child's Gender:
Child's Age:
Date of Birth:
Last school grade completed:

Name of parent(s):
Street Address:
City:
State:
Zip:
Home telephone:  (
)
Parent/caregiver's cell phone:  (
)
Home email address:
Home Church:
Allergies or other medical conditions:
In case of emergency, contact:
Phone:
Relationship to child: